Depression history taking

Taking a depression history is an important skill often assessed in OSCEs. It’s a key skill that you’ll require whichever speciality you’re heading towards. The guide below provides a structured framework to ensure that all of the key points are covered in addition to some stock phrases that may come in handy. Check out the depression history taking mark scheme here.

Use the patient’s own language when describing their feelings, and use this to get them to expand on their presenting symptoms. Repeating parts of phrases can help develop the consultation and show the patient you are listening and trying to understand.

Be careful with your “active listening” fillers – nodding and making affirmative noises to show engagement may be more appropriate than saying “Okay…”, you may accidentally re-affirm some of the patient’s negative beliefs about themselves or their situation.

Don’t be afraid to (sensitively) ask about suicide risk. Screening for risk and asking about suicide does not increase the likelihood of a patient attempting it!

Signpost and summarise as you go.

Definition of depression

ICD-10 criteria

Depression is;

persistent sadness or low mood; and/or

loss of interests or pleasure

fatigue or low energy

At least one of these, most days, most of the time for at least 2 weeks.

Additional symptoms to ask about include:

Sleep

Appetite

Concentration

Low confidence

Suicidality

Agitation

Slowing of movements

Guilt

These will help you to determine the severity of depression, as shown in the table below.

Not depressed

<4 symptoms

Mild depression

4 symptoms

Moderate depression

5-6 symptoms

Severe depression

7 symptoms +/- psychotic symptoms

Symptoms should be present for a month or more and every symptom should be present for most of every day.

Opening the consultation

Introduce yourself – name/role

Confirm patient details – name/DOB

Confirm reason for presentation:

“What’s brought you in to see us today?”

Open questions can help the patient to explain how they are feeling, without placing words into their mouth or assuming a specific reason for presentation.

Developing a rapport

Enquiring about mood and general feelings before jumping into a history may help the patient feel more at ease:

“How are you today?”

“How have you been feeling recently?”

Screening for core symptoms

Screen for core symptoms of depression :

persistent sadness or low mood; and/or

loss of interests or pleasure (anhedonia)

fatigue or low energy

“In the past month have you…”

Felt down, depressed or hopeless?

Found that you no longer enjoy, or find little pleasure in life?

Been feeling overly tired?

Assessing symptoms of depression

Screen for the presence, and assess the extent of any biological symptoms.

Biological symptoms

Sleep cycle

“How has your sleep pattern been recently?”

“Have you had any difficulties in getting to sleep?”

“Do you find you wake up early, and find it difficult to get back to sleep?”

Mood

“Are there any particular times of day that you notice your mood is worse?”

“Does your mood vary throughout the day?”

“Do you find that your mood gradually worsens throughout a day?”

Appetite

“Have you noticed a change in your appetite?”

“What is your diet like at the moment?”

“What are you eating in a typical day?”

Libido

“Have you noticed a change in your libido?”

“Since you have been feeling this way, have you noticed a difference in your sex drive?”

Cognitive symptoms

Screen for, and assess the extent of any cognitive symptoms of depression.

When asking these questions, you may find it useful to use a lead-in. This allows you to signpost, maintain the patient’s trust, and normalise any feelings they may have, enabling an open conversation.

“People who feel the way that you have been describing can experience some seemingly bizarre events and feelings…”

“Have you ever heard voices speaking when there seems to be no-one around?”

“Do you ever feel that people are discussing you negatively?” (If so, get context!)

“Do you fear that people may be ‘out to get you’?”

“Have you ever felt that something or someone is able to put thoughts into your head?”

“Have you ever felt that something or someone can remove thoughts from your brain?”

“Have you noticed any sensations that seem odd or inexplicable?”

Assess risk

Assess suicide risk, and risk of harm to self.

Again, this is something that you may feel more comfortable approaching with a lead-in!

“When people feel down and depressed, they can feel that life is no longer worth living. Have you ever felt like this?”

“Have you had any thoughts of taking your life?” (if so – how often, when) / “Have you thought of how you would do something like this?” /“Have you made any plans?” / “Have you ever tried to take your own life?”

“Have you tried to hurt yourself in any way?” If so, how – if not “Have you thought of hurting yourself?”

“What things do you have that you feel stop you from harming/killing yourself?”